TY - JOUR
T1 - Advantages and pitfalls of combining device-based and pharmacologic therapies for the treatment of ventricular arrhythmias
T2 - Observations from a tertiary referral center
AU - Rajawat, Yadavendra S.
AU - Patel, Vickas V.
AU - Gerstenfeld, Edward P.
AU - Nayak, Hemal
AU - Marchlinski, Francis E.
PY - 2004/12
Y1 - 2004/12
N2 - Device-based therapy has become the treatment of choice in the majority of patients for primary and secondary prevention of lethal ventricular arrhythmias with continually expanding indications for their use. However, despite the high efficacy of device-based therapy, many patients with an ICD will still require adjuvant pharmacologic therapy for optimal management of their arrhythmias. To date, only a few randomized studies have evaluated the effects of antiarrhythmic agents for optimizing ICD therapy. While sotalol has been shown to effectively reduce the frequency of ICD shocks, many of the patients who require concomitant antiarrhythmic drug therapy to prevent ICD shocks have poor ventricular function and low cardiac output and cannot tolerate the hemodynamic effects of sotalol. A preliminary pilot study has suggested that azimilide, a class III agent, is effective in reducing the number ICD shocks in patients with reduced left ventricular systolic function. In addition, this drug was well tolerated and did not seem to have significant effects on DFT. The results of this pilot study were intriguing but still need to be confirmed in a large patient cohort and The Shock Inhibition with Azimilide (SHEILD) study is currently in progress to confirm these results. The OPTIC is another randomized study in progress to evaluate the effectiveness of antiarrhythmic drugs for preventing shocks in patients with an ICD. The OPTIC trial proposed that combined treatment with amiodarone and β-blockers or sotalol alone would reduce the occurrence of ICD shocks compared to treatment with a β-blocker alone. Importantly, the management of patients with arrhythmia disorders and left ventricular dysfunction is constantly evolving. For example, the recent approval of biventricular ICDs, along with preliminary data suggesting these devices may reduce recurrence of VT, and will perhaps reduce the need for concomitant drug therapy in selected patients. In closing, the authors feel that the state of current practice dictates that the management of ventricular arrhythmias should include the ability to recognize the indications and benefits of combining device-based and pharmacologic treatments. Just as important, a complete understanding of the potential pitfalls of hybrid therapy and how to avoid them is required for optimal patient management. Because antiarrhythmic drug therapy may affect ICD function in a variety of ways as described, the authors strongly feel that the appropriateness of device sensing parameters and the efficacy of programmed therapy should be routinely assessed in most patients after the institution or modification of pharmacologic treatment.
AB - Device-based therapy has become the treatment of choice in the majority of patients for primary and secondary prevention of lethal ventricular arrhythmias with continually expanding indications for their use. However, despite the high efficacy of device-based therapy, many patients with an ICD will still require adjuvant pharmacologic therapy for optimal management of their arrhythmias. To date, only a few randomized studies have evaluated the effects of antiarrhythmic agents for optimizing ICD therapy. While sotalol has been shown to effectively reduce the frequency of ICD shocks, many of the patients who require concomitant antiarrhythmic drug therapy to prevent ICD shocks have poor ventricular function and low cardiac output and cannot tolerate the hemodynamic effects of sotalol. A preliminary pilot study has suggested that azimilide, a class III agent, is effective in reducing the number ICD shocks in patients with reduced left ventricular systolic function. In addition, this drug was well tolerated and did not seem to have significant effects on DFT. The results of this pilot study were intriguing but still need to be confirmed in a large patient cohort and The Shock Inhibition with Azimilide (SHEILD) study is currently in progress to confirm these results. The OPTIC is another randomized study in progress to evaluate the effectiveness of antiarrhythmic drugs for preventing shocks in patients with an ICD. The OPTIC trial proposed that combined treatment with amiodarone and β-blockers or sotalol alone would reduce the occurrence of ICD shocks compared to treatment with a β-blocker alone. Importantly, the management of patients with arrhythmia disorders and left ventricular dysfunction is constantly evolving. For example, the recent approval of biventricular ICDs, along with preliminary data suggesting these devices may reduce recurrence of VT, and will perhaps reduce the need for concomitant drug therapy in selected patients. In closing, the authors feel that the state of current practice dictates that the management of ventricular arrhythmias should include the ability to recognize the indications and benefits of combining device-based and pharmacologic treatments. Just as important, a complete understanding of the potential pitfalls of hybrid therapy and how to avoid them is required for optimal patient management. Because antiarrhythmic drug therapy may affect ICD function in a variety of ways as described, the authors strongly feel that the appropriateness of device sensing parameters and the efficacy of programmed therapy should be routinely assessed in most patients after the institution or modification of pharmacologic treatment.
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U2 - 10.1111/j.1540-8159.2004.00702.x
DO - 10.1111/j.1540-8159.2004.00702.x
M3 - Review article
C2 - 15613132
AN - SCOPUS:11144341490
SN - 0147-8389
VL - 27
SP - 1670
EP - 1681
JO - PACE - Pacing and Clinical Electrophysiology
JF - PACE - Pacing and Clinical Electrophysiology
IS - 12
ER -